Active management of the third stage of labour means that women lose less blood than with a more expectant approach, reveals a thesis from the University of Gothenburg, Sweden, in conjunction with Sahlgrenska University Hospital.
A number of studies in the West have shown that heavy bleeding following childbirth has become more common in recent years. In her thesis, midwife and researcher Elisabeth Jangsten decided to look at how heavily women bleed after giving birth in Angola and Sweden following active and expectant management. The study in Angola covered 1,590 women, while the Swedish study included 1,802. The Swedish study was conducted at two of the delivery units at Sahlgrenska University Hospital, which make use of both active and expectant management.
Active management means that the umbilical cord is clamped straight after the baby is delivered, the midwife gives the mother medication to stimulate uterine contractions, presses a hand on the lower part of the uterus, and pulls gently on the umbilical cord while the mother pushes, so delivering the placenta. With an expectant approach, the umbilical cord is also clamped straight after the baby is delivered, but the midwife then waits for signals that the placenta has separated from the wall of the uterus before encouraging the mother to bear down and push out the placenta. Uterine stimulants are always given if the need arises.
"In Angola, 7.5% of women lost more than a litre of blood in the expectantly managed group, and only 1% in the actively managed group," says Jangsten, a midwife at Sahlgrenska University Hospital/Östra Hospital and researcher at the Institute of Health and Care Sciences at the Sahlgrenska Academy. "In Sweden, the difference was bigger: almost 17% of women lost more than a litre in the expectantly managed group, and only 10% in the actively managed group."
The researchers did not find any difference between the two methods in terms of perceived afterpains in either Sweden or Angola. However, afterpains were more common the more children the women had had. They also found that first-time mothers in Sweden lost more blood and were more likely to require a blood transfusion than those who had given birth before. More women bled heavily in the Swedish study, which can be explained partly by all blood being measured carefully during the course of the study, but may also be down to other factors, such as excess weight, big babies and greater intervention during childbirth.
The recommendation in Sweden has been to give mothers uterine stimulants immediately after delivery.
"But not every element of the active management approach is always included, although the World Health Organisation, the International Confederation of Midwives and the International Federation of Gynaecology and Obstetrics have been recommending active management for a number of years, albeit with slightly later clamping of the umbilical cord," says Jangsten.
However, administering uterine stimulants routinely following all types of delivery has been questioned by those who believe that there should be as little medical intervention in childbirth as possible in order not to disrupt the natural process. They believe instead that treatment should be given only if the situation requires it.
"In the light of our results in this thesis, I think that active management should be the first choice for hospital deliveries. However, women should be informed about the different methods available so that they can be involved in decisions about the management of the third stage of labour if they so wish."
Postpartum haemorrhage is the medical term for bleeding following childbirth, both before and after the placenta is delivered. Total blood loss is normally around 600 ml, but sometimes the bleeding is heavier because the placenta does not separate properly from the uterus, or because the muscles in the walls of the uterus do not contract strongly enough. If this happens, the mother is given medication to stimulate uterine contractions, and sometimes the placenta may need to be removed manually.